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  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    (PPVI)

    BASIL D. THANOPOULOS MD, PhD

    Director Interventional Cardiology of CHD

    Euroclinic

    ATHENS - GREECE

  • Surgical implantation of valved aortic homografts orheterografts is the initial procedure of choice forpatients with tetralogy of Fallot and severe pulmonarystenosis or atresia. This surgical procedure can beperformed with low mortality and rate of complicationsin experienced centers, but valved conduits have limitedlifespan, less than 10 years. As a result, the majorityof patients with right ventricular outflow tract conduitswill undergo multiple re-operations with increasedcomplexity and surgical risk as a result of conduitstenosis and/or insufficiency, particularly, if the initialsurgery was performed early in life.

    TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    70000 worldwide

    Conduit failure

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    RATIONALE

    Help to reduce the total number of surgeries over the patients lifetime by postponing time to surgery while

    restoring pulmonic function

    Option to intervene earlier, providing better outcomes for patients while avoiding

    surgical complications

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    Available pulmonary valves

    Melody valve

    Edwards Sapien THV

  • Melody transcatheter pulmonary valve

    TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

  • The percutaneous implantation of pulmonaryvalve in patients with dysfunctioning RV topulmonary artery conduits is considered to bethe most exciting advancement ininterventional pediatric cardiology the last 5years.

    TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    BONHOEFER ET AL 2000

    12-Year-old boy with stenosis

    and insufficiency of a RV-PA

    conduit

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    CONDUIT FAILURE(Stenosis + insufficiency)

    Progressive RV dilation can lead to eventual heart failure

    Enlarged RV can be arrhythmogenic-AF

    RV dysfunction can ultimately lead to LV dysfunction

    RV failure can lead to early mortality

    Timely intervention can save RV function and regress dilatation

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    INDICATIONS

    A. Patients with stenotic and/or regurgitantprosthetic right ventricular outflow tract (RVOT)conduits with a clinical indication for invasive orsurgical intervention.

    1. Doppler gr 40 mm Hg

    2. Moderate to Severe PR

    3. RVEDV 150-170 ml/m

    4.RV Fractional area 40%

    B. Existence of a full RVOT conduit 16 mm/ 22 mm when originally implanted.

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    RESULTS(Melody valve implanters: MS Vienna 2015) *

    1000 pts-FU 2006-2013(694:1Y FU)

    RVOT obstruction: 40%

    PR: 20%

    Mixed: 30%*= 8000 Pts

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    RESULTS(Melody valve implanters: MSR Vienna 2015) *

    No significant residual gradient

    PR: p 0.01 (+-++/ 72 months)

    RVEDV + RVESV

    Exercise capacity

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    COMPLICATIONS(Melody valve implanters: MSR Vienna 2015)

    Mortality

    Early: 1 pt Late: 6 pts

    Homograft rupture: 3 pts

    Dislodgment of the stented valve: 2 pts

    Stent fracture: 8-20%-

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    Stent fracture: 8-20%

  • Mortality

    Early: 1 pt Late: 4 pts

  • AEPC 2011

    TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    PPVI Versus SI/R

  • GREEK EXPERIENCE

    25 patients

    (Stenotic regurgitant)

    Native RVOT: 2 pt

    Dysfunctioning aortic homograph: 19 pts

    TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    Gore-tex conduit: 1pt

    RVOT patch: 1 pt

    Magna Ease valve : 1 pt

    Hancock conduit: 1 pt

    Age 8-31 years

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    GREEK EXPERIENCE

    Surgical history

    TGA + PS: 3 pts

    Ross procedure: 4 pts

    Previous surgical conduit replacements2-3 : 8 pts

    TOF + APV: 2 pts

    TOF + PA: 16 pts

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    GREEK EXPERIENCE

    RVOT obstruction: 14 pts

    Mixed (PR): 9 pts

    PR : 2 pts Hemodynamic data

    PGr: 40-110 mm Hg PR: + -+++

    Dysfunctioning RV12 pts: (EF

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    GREEK EXPERIENCE

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    GREEK EXPERIENCE

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    Greek experience

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    GREEK EXPERIENCE

    Native RVOT-TGA

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    GREEK EXPERIENCE

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    GREEK EXPERIENCE

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    GREEK EXPERIENCE

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    GREEK EXPERIENCE

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    GREEK EXPERIENCE

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    GREEK EXPERIENCE

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    GREEK EXPERIENCE

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    EDWARDS SAPIEN VALVE

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    HANCOCK VALVE CONDUIT

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    GREEK EXPERIENCE

    Results

    PGr: 0 25 mm Hg

    PR: 0 (23 pts) Trivial (2pts)

    ComplicationsPrestent embolization: 2 pts

  • GREEK EXPERIENCE

    Complications

    TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    FOLLOW-UP

    Clinical examination

    2-D + Doppler echocardiography

    ECG Holter monitoring

    Chest x-ray

    Cardiac MRI (MSCT)

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    GREEK EXPERIENCE

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    GREEK EXPERIENCE

    STENTEXPANSION

  • 26 mm 23 mm

    TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    22-24F DS

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    EDWARDS SAPIEN VALVE

    GLOBAL EXPERIENCE:36 PTSKenny et al (JACC 2011)

    Results

    Success: 31/36 (86%)Dgr=15-20 mmHgNo significant PR

    Complications:Embolization: 3 pts

    VF: 2 pts

    Follow-up: 6 mNo valve failure (1 pt)

    No stent fractures

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    EDWARDS SAPIEN VALVE

    Comparative outcome of the Edwards-Sapien and Melody valve

    Faza et al (CCI 2013)

    Melody valve (13 pts) ES valve 20 pts)

    Men RSG =11.2 mm Hg Men RSG =11.2 mm Hg

    Stent migration 1 ptStent migration -

    No deaths

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    Medronic native outflow tract device

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    Venous-P Valve

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    Melody transcatheter pulmonary valve

    CONCLUSIONS I

    Transcatheter replacement of pulmonary valve using

    the Medronic pulmonary valve implant is a safe andeffective alternative to open heart surgery for thetreatment of selected patients with dysfunctioningvalve conduits. Close collaboration between CongenitalCardiac Surgery and Cardiology teams are key to long-term success!!

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    CONCLUSIONS II

    RV to PA conduits are currently a great first step topulmonary blood-flow repair.

    The Melody in its current design is not intended toreplace the surgically placed conduit but is insteadintended to extend the life of that conduit and reducethe number of operations over the total lifetime ofpatients . Further research is required to improve theimplantation techniques and outcome of

    percutaneous pulmonary valve replacement therapy andto extend it to all patients with a clinical indication to

    delay or avoid open heart surgery.

  • TRANSCATHETER REPLACEMENT OF THE TRICUSPID VALVE

    CONCLUSIONS II

    Transcatheter tricuspid valve in valve implantation

    using the Medronic pulmonary valve or the EdwardsSapien valve implants is a new techique that can beused as an effective alternative to surgical valvereplacemt in selective high risk patients withdisfunctioning biological tricuspid valves.However,further studies are required to document its efficasy,safety and long-term results in a larger patientpopulation.

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    RESULTS(Melody valve-Bonhoeffer: PICS 2008)

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

  • TRANSCATHETER TRICUSPID VALVE IN VALVE IMPLANTATION

    Godart et al TTVI : A multicenter French studyArchives of Cardiovascular Disease 2014

    ComplicationsEmbolizationEndocarditis

    CAVBValve failure

    Death

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    EDWARDS SAPIEN VALVE

    20F DS?Cobalt stent

  • TRANSCATHETER REPLACEMENT OF THE PULMONARY VALVE

    COMPLICATIONS(Melody valve-Bonhoeffer: PICS 2008)

    RPA obstruction: 1pt

    CA compression: 1pt

    Guide wire perforation: 1pt

  • GREEK EXPERIENCE

    TRANSCATHETER REPLACEMENT OF THE PULMON

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